Medical Research–You Get What You Pay For

Last week I attended the Sixth International Congress on Peer Review and Biomedical Publicationin Vancouver. Hosted by JAMA and the British Medical Journal, the Congress brought together 415 editors from 34 countries. The presentations focused on research about peer-review quality, publication bias, conflicts of interest, and the quality of reporting research. (I know, I know: some of you would rather have a root canal than hear about this stuff.) What I came away with was a new skepticism and a bit of dread.

A study in JAMA got a big splash in the New York Timeslast Friday. The editors reported findings from their evaluation of the presence of honorary authorship and ghostwriting in six of the major medical journals, including JAMA. They found that overall, 8% of articles had ghost authors. Among research articles, 12% had ghost authors. These are fairly close to findings from a survey done in 1996, showing that little has changed.

Another presentation by Canadian researchers examining investigators’ experiences with conflicts of interest reported that in industry-related clinical trials, only 44% of the investigators had access to all the data (as opposed to 72% in non–industry related trials).

So, despite the best efforts by many journals to ensure accuracyand transparency in reporting research, it may be impossible to do so unless authors and investigators adhere to the same standards. AJN requires authors to disclose ties, financial and otherwise, to companies with products mentioned in their papers. This is not to imply any guilt, but to inform the reader of the ties and to acknowledge that there may be some potential bias.

Decisions about health care treatment are based on research. If research results are based on incomplete data or written by someone paid (often by pharmaceutical companies) to present results in a favorable light (and the two studies reported above indicate that this happens far too often), how can we trust in the results? How can we confidently base our practice on evidence if we can’t trust the evidence?

Medical editing: a ‘public good.’ My feeling of dread comes from the presentation by Harold Sox, former editor of Annals of Internal Medicine and chair of the Institute of Medicine’s Committee on Comparative Effectiveness Research. In discussing the importance of publishing the results of research, Sox said, “The public relies on journals to evaluate research. Good medical editing is a public good, but it’s expensive.” He’s right. Maintaining a high-quality editorial office to do the fact-checking (we check every reference to ensure it’s cited accurately); do our own search of the literature (to ensure seminal and new studies weren’t overlooked); and then do the careful editing that presents the content in a clear, accurate, concise, and interesting way is not cheap. But you get what you pay for.

He also asked, “If journal income declines, what happens to good medical editing?” Hence my feeling of dread—many nurses and other health care professionals feel that they can get information free on the Internet and so don’t see a need to subscribe to a professional journal. With less income, journal publishers feel the need to scale back staff and resources.

But someone is paying for the production of the content on the Internet—if it’s not a reputable organization or journal, who is it? Is it unbiased? Is it evidence-based, and who vetted the evidence and the authors? Let the readers—and their patients—be wary of what they read online and ask themselves just who paid for it, and why.

These are important issues to address but one must draw the distinction between ghostwriting and support provided by medical writers. Being transparent about what support has been provided and who has paid for it is important for the reader to be aware of any potential bias. There are other debates that may be of interest on this topic at:

Shawn Kennedy makes some important points in this blog post. Money counts, and too often we are lured by free information that comes to us in our mailboxes and in-boxes. And it’s so easy – we don’t have to renew a subscription or membership. But it really is a case of ‘buyer beware’ and I think we have a responsibility to our patients and profession to spread the word about the potential for bias in these freebies. We cannot and should not take a leaf out of the book of our medical colleagues whose track record, as Shawn points out, is not that stellar!